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Head / Neck Radiation Patients

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Oral Complications of Head and Neck Radiation

The oral complications of head and neck radiation can be divided into two groups on the basis of the usual time of their occurrence:

  • Acute complications occurring during therapy.
  • Late complications occurring after radiation therapy has ended.

Acute complications include the following:

  • Oropharyngeal mucositis.[1]
  • Sialadenitis and xerostomia.
  • Infections (primarily candidiasis).
  • Taste dysfunction.

Occasionally, tissue necrosis can be seen late during therapy, but this is relatively rare.

Chronic complications include the following:

  • Mucosal fibrosis and atrophy.
  • Decreased saliva secretion and xerostomia.[1]
  • Accelerated dental caries related to compromised saliva secretion.
  • Infections (primarily candidiasis).
  • Tissue necrosis (soft tissue necrosis and osteonecrosis).
  • Taste dysfunction (dysgeusia/ageusia).
  • Muscular and cutaneous fibrosis.[1]
  • Dysphagia.[2]

Management of oral mucositis

The etiopathogenesis of mucositis caused by head and neck radiation appears to be similar but not identical to mucositis caused by high-dose chemotherapy.[3,4,5] Management strategies described for chemotherapy/hematopoietic stem cell transplantation are generally applicable to the head/neck radiation patient.[6,7] (Refer to the Management of mucositis section of this summary for more information.) In one study, gabapentin appeared promising in reducing the need for narcotic pain medication for patients with head and neck malignancies treated with radiation therapy.[8][Level of evidence: III]

The extensive duration and severity of radiation mucositis combined with the treatment of most radiation patients as outpatients results in pain management challenges. As mucositis severity increases and topical pain management strategies become less effective, it becomes increasingly necessary to depend on systemic analgesics to manage oral radiation mucositis pain:[9]

  • Because there is generally no risk of bleeding for head and neck radiation patients, analgesic treatment begins with nonsteroidal anti-inflammatory drugs (NSAIDs).
  • As pain increases, NSAIDs are combined with opioids, and patients can be made relatively comfortable.

Doses for NSAIDs are titrated up to their recommended dosing ceiling; on the other hand, opioids are titrated to effective pain relief. Systemic analgesics are given by the clock to achieve steady-state blood levels to provide adequate pain relief.

Additionally, adjunctive medications are given to provide adjuvant analgesia and manage side effects of NSAIDs and opioids. Zinc supplementation used with radiation therapy may improve mucositis and dermatitis.[10][Level of evidence: I] The use of alcohol-free povidone-iodine mouthwash may reduce the severity and delay the onset of oral mucositis caused by antineoplastic radiation therapy.[11][Level of evidence: I]

Early infections

A systematic review indicated that the weighted mean prevalence of clinical oral candidiasis during head and neck radiation therapy is 37.4% and may be significantly higher in patients who receive concurrent chemotherapy.[12] Factors promoting clinical fungal infection in this population include the following:

  • Hyposalivation resulting from radiation damage to the salivary glands.
  • Tissue damage caused by radiation-induced oral mucositis.
  • Resulting dietary impairment.
  • Inability to maintain oral hygiene.
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